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What Is a PHP Medicare Psych?

Partial hospitalization programs (PHPs) are intensive short-term mental health interventions that may provide an alternative to inpatient psychiatric hospitalization for some patients. Medicare pays for PHP care (subject to the usual 20 percent co-payment) if its coverage criteria are met.

  1. Features

    • PHPs treat individuals with acute psychiatric problems, usually in a hospital outpatient department or community mental health center. The short-term treatment program often consists of extended daily sessions (e.g., six hours a day) five days each week.

      Services include individual, group and couples/family psychotherapy, medication management and other mental health care. Patients return home each evening to resume daily routines and practice newly acquired coping skills.

    Treatment Duration

    • Most PHPs admit only individuals likely to benefit from intensive, short-term interventions. The average length of treatment is four to five days.

    Medicare Coverage Criteria

    • Medicare requires that PHP services be active, intensive and therapeutic. In order for Medicare to cover PHP psychiatric services for a specific patient, the patient's physician must certify that, without PHP services, the patient would require inpatient psychiatric treatment. This certification must come from a Medicare-participating physician recommending a Medicare-participating PHP.

    Medicare Payment

    • Medicare sets payment limits for PHP services, regardless of the amount the specific PHP may charge. The patient (or his Medicare supplemental policy) pays 20 percent of the Medicare-approved amount, and Medicare pays the remaining 80 percent of the approved amount.

      Medicare-participating PHPs cannot charge Medicare beneficiaries more than the Medicare-approved amount.

    Medicare PHP Scrutiny

    • Treatment in a PHP can represent significant Medicare program savings over inpatient hospitalization. Unfortunately, there are instances in which programs admit patients who do not benefit from the services, or for whom intensive services are not medically necessary. The government's examination of several of these programs uncovered inappropriate Medicare billing for approximately half of the patients treated.

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